MANAGEMENT OF HEART

FAILURE

Prof R Moulds
Internal Medicine
FSM Modified 2009 by Dr. Mai Ling Perman
Overview
 Definition
 Pathophysiology
 Underlying causes of heart failure
 Precipitating causes of heart failure
 Diagnosis and differential diagnosis
 Prognosis
 Management
 Drug treatment
 Surgical treatment
Definition
 “The pathophysiological state in which an
abnormality of cardiac function is responsible for
the failure of the heart to pump blood at a rate
commensurate with the requirements of
metabolising tissues.”
Pathophysiology
 Reduction in cardiac output leads to:
 Reduced organ blood flow - particularly renal blood
flow
 Reduced blood pressure
 These stimulate compensatory mechanisms
 Renin - angiotensin system, leading to sodium (and
water) retention and also vasoconstriction
 Sympathetic nervous system.
Pathophysiology (cont)
 These cause an increase in both preload (due to the
fluid retention) and afterload (due to the increase in
blood pressure) of the heart.
 The increase in preload stretches the myocardium,
leading to increased contractility (Starling’s law)
 The increase in afterload also increases myocardial
contractility, as does also the increased sympathetic
nervous activity
Pathophysiology (cont)
 Cardiac output is therefore restored, but at the
expense of an increase in venous pressure (caused
by the fluid retention) and a tachycardia (caused by
the sympathetic stimulation)
Pathophysiology
Underlying causes of heart failure
 Rheumatic valvular disease
 Coronary artery disease (ischaemic heart disease)
 Hypertension (both acute and chronic)
 Congenital heart disease
 Others
 Cardiomyopathies
 Myocarditis
Precipitating causes of heart failure
 Anaemia
 Arrhythmia
 Myocardial infarction
 Pulmonary embolus
 Hypertension (acute)
 Infection
 Thyrotoxicosis
Diagnosis
 Does the patient have heart failure?
 If so, what is the underlying cause?
 In addition to the underlying cause, is there a
precipitating cause?
Diagnosis of heart failure - key features

 Raised venous pressure

 Right sided -> peripheral oedema (swelling of the
ankles, ascites etc)
 Left sided -> pulmonary oedema (shortness of breath)
 Enlargement of the heart
 Tachycardia
Diagnosis - History
 Of failure
 Shortness of breath
 On exercise
 Orthopnoea
 Paroxysmal nocturnal dyspnoea
 Swelling of the ankles
 improves at night
 Swelling of the abdomen (ascites)
Diagnosis – History
 Of cause and/or precipitating factors
 Past history
 ?known valvular disease
 ?known ischaemic heart disease
 ?known hypertension
 Chest pain
 Weakness and tiredness (?anaemia)
 Palpitations
 Thyroid disease
Diagnosis – physical examination
 Of failure
 Raised venous pressure
 Jugular veins assessed and vertical height of column of blood above
the right atrium estimated (normal 0-5 cm)
 hepatomegaly
 Cardiac enlargement – displaced apex beat
 Extra heart sounds – H3, H4, gallop rhythm
 Peripheral pitting oedema
 Crackles at the lung bases
 Other signs of excessive fluid retention
 Ascites
 Pleural effusions
Diagnosis – physical examination
 Of cause and/or precipitating factors
 Heart murmurs
 Valvular disease
 Congenital heart disease
 Hypertension
 Pallor (?anaemia)
 ?arrhythmia
 ?signs of thyroid disease
Diagnosis – investigations (to confirm
failure and to seek cause)
 Chest Xray
 Cardiomegaly
 Pulmonary venous congestion/oedema
 Abnormal cardiac contour
 ECG
 Rhythm
 ischaemic changes
 Chamber hypertrophy
 Echocardiography
 Valve function
 Chamber enlargement
 Thickened ventricular wall/regional wall motion abnormality
 Left ventricular ejection fraction
 Investigations
 Chest Xray
Diagnosis – investigations (cont)
 Full blood count
 Renal function tests and electrolytes
 (Thyroid function tests)
 (liver function tests, including serum albumin)
Differential diagnosis
 Other causes of shortness of breath
 Asthma/COPD
 Other respiratory diseases
 Pleural effusion
 Infection – acute (eg pneumonia) or chronic (eg
bronchiectasis, TB)
 Infiltrative lung diseases
Differential diagnosis (cont)
 Other causes of oedema and/or ascites
 Nephrotic syndrome
 Chronic liver disease
 Malignant ascites
 Venous obstruction
 Inferior vena cava
 Bilateral varicose veins
 Severe hypoalbuminaemia
Prognosis
 Depends mainly on the underlying cause, and in
particular on whether or not it is curable/treatable
 Hypertension – good prognosis
 Valvular disease
 Correctable by surgery – good prognosis
 Not correctable by surgery – bad prognosis
 Ischaemic heart disease
 Correctable with surgery – reasonable prognosis
 Not correctable with surgery – bad prognosis (death within ~one
year)
Management - general
 Treat the failure
 Salt restriction, lifestyle changes
 Drugs
 Diuretics
 ACE inhibitors
 Digoxin
 (Beta – blockers)
 Treat underlying causes where possible
 Treat precipitating causes where possible
 Prevent complications, eg emboli
Drug treatment of failure
 Usually commence with a diuretic
 Thiazide in mild cases – relieves symptoms
 Frusemide in more severe cases
 Spironolactone has been shown to improve prognosis in
severe cases
 Use ACE Inhibitor (or A2 antagonist) early in
treatment
 These drugs have been shown to increase life expectancy as
well as improve symptoms
Drugs (cont)
 Digoxin is still a useful drug
 Particularly if the patient is in atrial fibrillation (a common
arrhythmia)
 Also has been shown to be of some benefit in patients with
severe heart failure and sinus rhythm
 Difficult drug to use because of adverse effects
 Beta blockers are now used, because they have been
shown to prolong life. However they can make
failure worse when first commenced
Monitoring therapy
 Improvement of symptoms
 Improvement in physical signs
 Daily weighing (if in hospital and oedematous)
 Improvement in investigational findings e.g. Chest
Xray
Other aspects of drug treatment
 Note that the drugs are reversing the body’s
compensating mechanisms
 So the patient goes back to having reduced blood flow to
the kidneys, and renal function deteriorates with treatment
 Treatment also alters electrolytes – particularly
potassium
 Therefore monitor renal function and electrolytes
Other aspects of drug treatment (cont)
 Anticoagulation
 Some patients with heart failure are in danger of
systemic emboli from blood clots forming within the
heart (usually the left atrium)
 Valvular disease – particularly mitral valve
 Atrial fibrillation

 These patients may need long term anticoagulation

to prevent emboli
Other aspects of drug treatment (cont)
 Underlying cause might need long term drug
treatment
 Ischaemic heart disease
 Aspirin
 Statin
 Hypertension
 Drugs for failure also treat hypertension
 Penicillin prophylaxis for rheumatic valvular heart
disease
Surgical treatment
 Some causes of heart failure can be treated
surgically, depending on the individual situation
 Coronary artery bypass/angioplasty
 Valve replacement or other operation to improve valve
function
 (Removal of ventricular aneurysm)
Summary
 Heart failure is a common clinical syndrome
 The diagnosis of heart failure is made from the
history, physical examination, and with appropriate
investigations
 We must look for, and treat where possible, the
underlying cause and precipitating causes
 Drug treatment is the mainstay of management in the
majority of patients.